Socio-economic determinants of unmet need for gender-confirming healthcare

Objective: To examine the extent to which income and health insurance determine unmet need for gender-confirming care for transgender and gender non-conforming adults. Methods: We used data collected from the National Transgender Discrimination Survey (n=6,456), a cross-sectional, non-probability survey of adults who self-identified as transgender or gender non-conforming. The sample was restricted to those who had desired or had received counseling, hormones, top surgery, or other gender-confirming surgeries. We used logistic regression models to explore health insurance and income to needs ratio as predictors of unmet need for gender-confirming healthcare. We adjusted for age, education, and perceived visual conformity, then stratified by gender identity. Results: Those without insurance are less likely to have received counseling (odds ratio [OR]=0.698) and top surgery (OR=0.801) compared to those with private insurance. The poor and near poor have a lower odds of receiving top surgery (OR=0.673-0.811) and other surgeries (OR=0.703- 0.742) compared to those living at more than 400% above the federal poverty line (FPL). Stratifying for gender identity generated differential effects in experiences of unmet need, particularly for hormones and top surgeries. Female-to-male (FTM) adults who lived below the poverty line were more likely to have an unmet need for hormones. Conclusion: Income and private health insurance are strong predictors of unmet need for gender-confirming healthcare. These barriers to accessing health services may continue to perpetuate and even exacerbate the psychological and somatic health of transgender people.